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Client Registration Form

Please fill out the following form

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Are you taking any medication
Please tick any box which applies to you
Are you in pain
Intermittent
Permanent

STATEMENT AND CONSENT OF CLIENT, DATA PROTECTION AND CLIENT CONFIDENTIALITY

 

I declare that all the above given information is true and to the best of my knowledge. I confirm that I do not have any infectious diseases, and I agree to inform the practitioner should my health condition change or deteriorate.

I am aware that Amatsu does not replace diagnostic test and treatments available from my Doctor, the National Health Service or private medical care. I agree to retain my doctor as my principal healthcare provider, consulting them as appropriate. I understand that I must consult with my doctor before reducing or withdrawing any prescribed medication.

I understand that Amatsu uses touch and mobilisation. Acupuncture uses needles that penetrate the skin. I consent to the Practitioner holding and moving my body, and the use of acupuncture needles to facilitate the treatment.

I understand that Ozone Therapy uses venipuncture, injections and or insufflation. I consent to these procedures.

I agree that Stephan J Grabner, in accordance with the GDPR, may hold and process the personal data in this form, and any other data relating to my treatment. All information will be strictly private and confidential. should consultation or referral be necessary, the Practitioner will obtain the clients permission before disclosing any information.

 

 

 

 

 

CANCELLATION POLICY:

Appointments cancelled in less that two working days prior to treatment will incur a  charge of 50% of the fee!

No shows and appointments cancelled in less that one working day prior to treatment will incur a 100% of the fee!

Please do not sign this form if you do not agree with the cancellation policy!!

CAN I CONTACT YOU FROM TIME TO TIME BY EMAIL FOR OFFERS AND NEWS?

Thanks for submitting!

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